HomeMy WebLinkAboutPermit Mechanical 1994-4-18
WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD .
BUILDING SAFETY DIVISION
u&R
225 Fifth' Street
Springfield, Oregon 97477
Office: 726~3759
INSPECTION LINE: 726-3769
Job Locadon:
35"3 ,~(?lds~ Sp0r\~'~fJd" DR-- ,Qllfi7 .,', ',' ',:'.,
\nQ~'~~' Tax Lot #: O~1n()
Assessors Map #:
- '
Owne~:thu\d. ~ [)t\V\f\Cl 'Sp(de.-il
, ,~ " " " , ,
Address: ~S2) ~I ?\r1csinne_
City: L~V(Vl,~PLd' State:
Value of Y, od Stov /Pellet Stove/Insert:
(plea e appropriate appliance)
Phone
#: ~zIb -(dlcf~
Zip: C/i1f77
(91-
{\ (\ )
Prelimin~ry Inspection is $15.00 (prior to installation of insert) .
Wood Stove/Pellet/Insert permi~s $15jOO + $ .75 state surcharge +
Type of Inspection Requested: \{)\ 01. Q f'f\.L(\;D...5LA..l
. Q
$10.00 Issuance.
Contractor:
f\~
Address:
Phone #:
City:
State:
Zip:
Construction Contractors Registration #: "il) 4
t
By signing this permit/application, I agree to call for an inspection(s) as required
(726-3769). I state that all information on this application/permit is correct and
that I was proviqed with the Wood Stove Safety information for wood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing meets smoke emission standards as set by the Oregon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing approval number to the inspector at the tim~ of inspection. I
also understand that if I am requesting a preliminary inspection, the wall covering
may be required to be.removed.
[)dJ{;Y(il d 4wM1
Signature /
Expires:
2j -ffrr!j sL
Date I
FOR OFFICE USE
Date of Application:
VOODSTOVE/PELLET/INSERT
O. ca.q~
\~,~
Job #:
. PREL~NARr )(
c{4CJ(c11\
REQUIRED INSPECTION(S):
Total Amount Collected:
Receipt II \l\\n1:9\
I
()
Issued By:
~
Checked for Delinquencies:
for Historical Status: